Healthcare Provider Details

I. General information

NPI: 1174253587
Provider Name (Legal Business Name): TRAVIS D. WAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 COLLEGE ST
BATTLE CREEK MI
49037-3432
US

IV. Provider business mailing address

175 COLLEGE ST
BATTLE CREEK MI
49037-3432
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 269-966-1460
  • Fax: 269-966-2844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6362009541
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: